Communication

Written By: Kristi Riker OTD, OTR/L

Parkinson’s disease can affect communication in a few very specific (and frustrating) ways because it impacts both verbal on nonverbal communication skills. Both of these types of communication rely on precise timing,

appropriate force (loud vs soft, big vs small gestures), smooth starting/stopping of movement, and automatic control. 

PD primarily affects motor regulation, so anything that depends on coordinated movement gets hit—including: voice, facial expression, eye gaze, gestures, posture, and timing.

Verbal Communication

Verbal communication barriers:

While it may be well known that Parkinson’s Disease generally affects muscle function, many people do not consider how PD impacts the muscles used specifically for speaking. This struggle unfortunately makes sense, as speech is one of the most complex motor tasks we do. 

Why does this happen? In short, PD degenerates dopamine-producing neurons in the substantia nigra, which disrupts basal ganglia–cortical loops that normally initiate speech, scale volume, and maintain rhythm. Some of the most common speech concerns for those with PD include:

• A softer voice

• A monotone voice

• A breathy or hoarse voice

• Tapered voice at the end of sentences

• Slurred speech

• Rate or rhythm changes (too fast or slow)

• Difficulty initiating speech

Speech Treatments:

• Speech language pathology support

• Speech therapy, such as the LSVT LOUD program

• Breathing and posture support

• Assistive voice amplification

• ‘SPEAK OUT!’ and ‘The LOUD Crowd’

  • Programs developed by the Parkinson Voice Project that emphasize speaking with intent and daily practice.

  • Often easier to access or more engaging for some than the intensive LSVT format.

•  Melodic Intonation / Rhythm-based Approaches

  • These use rhythm and melody to smooth out speech and pacing 

• Technology + Home Practice Tools

  • Apps and telepractice platforms that give feedback and help with practice compliance. These complement SLP sessions but aren’t replacements for clinician-guided treatment.

• Environmental cues:

  • Reminders from others to raise voice, slow down, etc.

  • Why does this help?

    • Intentional communication (thinking hard about speaking) uses cortical pathways while automatic communication (natural tone, facial reactions, spontaneous gestures) relies heavily on basal ganglia loops. PD disproportionately affects the automatic system, which explains why someone can speak loudly when cued but sounds quiet and flat in spontaneous conversation.

      
      

Verbal Exercises: 

• Voice & Loudness: Sustained vowel

  • Take a deep breath

  • Say “AH” loudly and clearly

  • Hold as long as you can with steady volume

  • Complete 10 reps

• Functional phrases: Say common phrases LOUD and clear

  • “Good morning”

  • “I need help”

  • “How are you?”

  • Complete 5–10 phrases, 2 rounds

• Pitch glides

  • Say “ah”  first low → high pitch, then high → low pitch

  • Keep it loud, not strained

  • Complete 5 each direction

• Articulation: Big mouth speech

  • Read a short paragraph

  • Over-open the mouth and over-move lips (exaggerate movements)

  • Imagine talking to someone hard of hearing

• Consonant drills

  • Say: “Pa-Ta-Ka”

  • Say“: Ba-Da-Ga”

  • Repeat for 10–15 seconds each, 2–3 rounds

• Precision words

  • “Buttercup”

  • “Tip-top”

  • “Peanut butter”

  • Say in slow and crisp manner, 5 rounds

• Pacing tap - helps when speech rushes or becomes hard to follow.

  • Tap finger once per word while speaking

  • Works great for sentences or reading aloud

• Pause practice

  • Say a sentence

  • Pause deliberately at commas and periods

  • Reset breath each time

• Diaphragmatic breathing

  • Hand on belly

  • Inhale through nose (belly expands)

  • Speak on the exhale

• Phrase-length control

  • Take one breath

  • Say a full sentence without fading at the end

Nonverbal Communication:

PD impacts nonverbal communication for essentially the same reason it affects verbal communication - it disrupts the brain’s motor control systems that coordinate automatic, expressive movement.

Nonverbal communication barriers:

• Reduced facial movement and expressiveness

• Fewer spontaneous smiles, eyebrow raises, or emotional reactions (the face may look neutral, serious, or “flat” even when the person feels engaged or happy)

• Decreased blinking (fixed or staring appearance)

• Eye contact may feel either overly intense or under-responsive

• Subtle eye movements that normally cue interest/understanding are reduced

• Fewer spontaneous hand and arm gestures

• Smaller, slower movements

• Reduced posture shifts and expressive body language

• Delayed responses (slower nodding, reacting, or facial feedback)

• Conversations can feel “off rhythm” which affects turn-taking – a big part of social communication

  
  

Nonverbal communication exercises:

• Emotion sentence

  • Say the same sentence or phrase with these different emotions: happy, curious, serious, excited

  • Helps coordinate facial movement with speech

    
    

• Mirror work

  • Practice speaking in front of a mirror

  • Watch mouth movement and facial expression

  • Practice exaggerated expressions: happy, surprised, sad, confused

  • Raise eyebrows, hold 5 seconds, relax, 10 times

  • Alternate between a big smile and relaxed face 

  • Focus on activating both sides of the face

    
    

• Gestures and Body Language

  • Arm and posture mobility – Shoulder rolls, arm lifts, and torso twists to help improve range of motion for expressive gestures

  • Role-play exercises – Practice conversational gestures with a partner: nodding, shrugging, indicating size or direction

  • Combine gestures with speech to reinforce expressive timing

    
    

• Eye Contact and Gaze (goal: maintain natural eye engagement in conversation)

  • Blink reminders – Practice deliberate blinking every 5–10 seconds to avoid staring or frozen gaze

  • Tracking exercises – Follow an object with eyes without moving the head to enhance control for subtle visual cues in conversation

    
    

• Timing and Turn-Taking Exercises (goal: smooth conversational rhythm)

  • Paced conversation – Practice a short dialogue with deliberate pauses for turn-taking.

  • Use a metronome or tapping to maintain rhythm.

  • Mirror turn-taking – practice nodding, eyebrow lifts, or hand gestures in response to someone else, exaggerating feedback to match cues

  • Tactile or visual cues: Set up your phone or apple watch to vibrate with reminders for posture, movement, blinking, etc. OR put up notes around the house as visual reminders to complete these

    
    

• Communication Partner Training

  • Teach conversation partners to: allow extra response time, recognize that muted expression does not equate to being emotionless, and encourage gestures or visual cues

    
    

Impact on relational connection

PD impacts the brain’s ability to interpret sensory feedback, making it easy to misjudge one’s own speech and expression. An individual with PD may think they’re speaking loudly when they’re actually quiet. They may feel expressive internally but appear emotionally flat externally. This feedback mismatch makes self-correction difficult and adds to the communication struggle. 

Misunderstandings occur, and others may misinterpret emotions or intent. Over time, this can lead to frustration, social withdrawal, and reduced confidence—making communication even harder. Nonverbal communication (smiling, touch, gestures) is key to showing love, empathy, and support and so reductions in expressiveness may be misinterpreted as detachment or lack of affection. 

Both the person with PD and communication partners are forced to work much harder to understand each other. Caregivers may feel responsible for prompting speech, repeating messages, or interpreting cues, which can lead to burnout over time.

What Can Care Partners Do?

• Care partners can focus on the core cause of these communication breakdowns. Miscommunication is not intentional—it’s a motor symptom. The individual with PD may be quiet, flat, and slow in communication, but still feel completely engaged and affectionate - focus on the intent. Assume intent based on words and context, not just expression. 

• Rather than interpreting lack of expression as disinterest, ask them to use their words to describe how they are feeling. 

• Since body language is often smaller, really focus on subtle cues and mannerisms that are unique to your partner. 

• Give extra time for responses as PD slows initiation of speech and gestures.

• Give gentle reminders such as, “could you try to nod and use your eyebrows more?” 

• Set aside time for meaningful connection - sit facing one another, lower background noise, encourage eye contact and physical touch, and emphasize your words and nonverbal communication. 

• Validate Feelings by reassuring your partner that you understand their emotion and intent even if the delivery looks different. 

• Encourage participation in group therapy, singing, or drama programs. 

• Celebrate successes in communication, not just correct speech. 

• Encourage them to practice nonverbal expression in private or mirror exercises to build confidence. Mirror practice together: exaggerate expressions and gestures, make it fun.

• Read aloud to each other. Focus on voice volume, facial expressions, and gestures. Cue cards or prompts: gentle reminders for expressive behaviors.

Resources:

Rohl A, Gutierrez S, Johari K, Greenlee J, Tjaden K, Roberts A. Speech dysfunction, cognition, and Parkinson's disease. Prog Brain Res. 2022;269(1):153-173. doi: 10.1016/bs.pbr.2022.01.017. Epub 2022 Feb 9. PMID: 35248193; PMCID: PMC11321444.

​​Schalling E, Johansson K, Hartelius L. Speech and Communication Changes Reported by People with Parkinson's Disease. Folia Phoniatr Logop. 2017;69(3):131-141. doi: 10.1159/000479927. Epub 2018 Jan 18. PMID: 29346787.

Sullivan L, Martin E, Allison KM. Effects of SPEAK OUT! & LOUD Crowd on Functional Speech Measures in Parkinson's Disease. Am J Speech Lang Pathol. 2024 Jul 3;33(4):1930-1951. doi: 10.1044/2024_AJSLP-23-00321. Epub 2024 Jun 5. PMID: 38838243.

Theodoros D, Anderson A. Speech therapy for people with Parkinson’s disease BMJ  2024;  386 :q1254 doi:10.1136/bmj.q1254